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Vermont closed out its nine-year All-Payer ACO Model at the end of 2025, capped what hospitals can charge for outpatient drugs, and lost its two largest Medicare Advantage carriers before the new year. A2Z Billings runs day-to-day medical billing and revenue cycle management for Vermont practices, built around the Green Mountain Care Board, DVHA, and the state's two-carrier commercial market.
Vermont has one Medicaid agency, two commercial carriers writing nearly every plan, and fourteen hospitals reporting to a single regulator. When any one of them changes a rule, it reaches most claims in the state within a billing cycle.
The Department of Vermont Health Access administers Medicaid through the state's Global Commitment to Health waiver, currently running through 2027. Close to 220,000 Vermonters are enrolled, roughly a third of the state and one of the highest Medicaid rates per capita in the country.
Blue Cross Blue Shield of Vermont, the state's only local not-for-profit health plan, and MVP Health Care cover most individual, small-group, and exchange members. A rule change at either carrier touches most privately insured practices in the state.
The Green Mountain Care Board sets an annual revenue growth cap for every one of Vermont's fourteen community hospitals, which together account for roughly 40% of the state's total health spending. The University of Vermont Medical Center and Dartmouth Health anchor the two networks most Vermont practices refer into.
Vermont rewrote how telehealth gets coded, how ACOs get paid, how hospitals charge for drugs, and which Medicare Advantage plans still exist here, all between January 2025 and January 2026.
Vermont Medicaid separated telehealth into two place-of-service codes: POS 02 for a facility-based originating site, POS 10 for a patient's home. Claims coded the old way started denying.
S.30 took effect, requiring Vermont health plans to reimburse telehealth visits at the same rate as in-person care when billed under equivalent codes and modifiers.
OneCare Vermont wound down after nine years, and the state's All-Payer ACO Model ended with it. Vermont moved to the federal AHEAD Model for 2026.
A statewide cap on hospital outpatient drug charges, tied to average sales price, locked in fully, alongside Vermont's first Medicaid hospital global budget.
Vermont Blue Advantage and UnitedHealthcare exited the individual Medicare Advantage market, leaving Humana as the only carrier, sold in just six counties.
"Claims logic built for OneCare's Vermont stopped working the day OneCare closed its doors."
Our coding team rebuilt place-of-service and modifier logic the week Vermont split telehealth billing, then rechecked payer contracts against the S.30 parity requirement before it took effect in September. Eligibility staff track which of Vermont's fourteen counties still carry an individual Medicare Advantage plan, so a Humana enrollee outside those six counties gets flagged before a claim goes out, not after it comes back.
On the hospital side, we track each facility's Green Mountain Care Board revenue order and the new average-sales-price drug cap by NDC, so infusion and oncology charges post at the rate the state allows rather than the rate an older chargemaster still assumes. Credentialing follows Vermont's gold-card statute, so practices that qualify stop submitting prior authorization on procedures the law already exempts.
Claims for Green Mountain Care, Medicare through National Government Services, and both commercial carriers, coded to the rules currently in force.
Telehealth-adjusted coding for Vermont's split place-of-service rules, with E/M and ICD-10 coding checked against payer-specific edits before a claim leaves.
Enrollment with DVHA Medicaid, Medicare through NGS, and both commercial payers, plus tracking for Vermont's gold-card prior authorization exemptions.
Full-cycle work from registration to zero balance, rebuilt this year around the AHEAD Model instead of OneCare's fee schedule.
Coverage checks that flag Medicare Advantage members whose plan is no longer sold in their county, before the visit rather than after the denial.
Requests tracked against Vermont's statewide gold-card exemptions, so approved providers stop filing paperwork the law no longer requires.
Denial patterns tied to Vermont's new telehealth and drug-charge rules, since a rate change in Montpelier shows up as a denial code before payer manuals catch up.
Posting checked against Green Mountain Care Board-approved rates and the average-sales-price drug cap, so underpayments surface quickly.
Aging balances worked early, before Vermont's slower rural claim cycle times stretch them out further.
Vermont's gold-card law applies most heavily here. A documented approval history removes prior authorization on routine imaging and drug-refill requests.
The new average-sales-price cap on hospital outpatient drugs hits infusion-heavy specialties directly. Charge capture now needs to match the state's cap, not an older chargemaster.
Telehealth for mental health and substance use disorder care stayed covered when Medicare's other telehealth flexibilities ended in January 2026, and Vermont Medicaid's audio-only code list still applies.
Vermont's older, rural population keeps referral volume steady. Prior authorization and Medicare Advantage network checks matter more here than in most specialties.
Nearly two-thirds of Vermonters live rurally, so referrals routinely cross into New Hampshire, most often into Dartmouth Health, and need to be billed accordingly.
Demographics and coverage confirmed against the Vermont Medicaid or exchange plan on file, not assumed from the last visit.
County-level Medicare Advantage availability checked before scheduling, since coverage now varies by county.
Every claim checked against Vermont's current telehealth and drug-charge rules before submission.
Entered against Green Mountain Care Board-approved rates and the state's drug-charge cap.
Filed electronically with Green Mountain Care, National Government Services, or the payer of record on the first pass.
Reconciled against approved rates the same week, so a shortfall is visible immediately.
Vermont-specific denial codes routed to the right fix within days, not the next billing cycle.
Timely appeals filed within Vermont's payer deadlines, with documentation drawn straight from the visit note.
Aging balances worked before Vermont's rural claim cycle times let them stretch out further.
Monthly reporting matched against Vermont's regulatory calendar, so a practice sees a rule change coming rather than after it hits the bottom line.
Rural America lost nearly 2,500 independent physicians and roughly 3,300 rural practices between 2019 and 2024, and Vermont, where about two-thirds of residents live rurally, felt that shortage directly. In the same stretch, the state closed out a nine-year payment model, capped hospital drug charges, split telehealth billing in two, and watched Medicare Advantage collapse to a single carrier in six counties, all within about a year. Billing built for the old rules falls behind fast when there's no one left in-house to rebuild it.
Yes. Our team works Eastern time and follows Vermont's payer deadlines directly, including Green Mountain Care Board filing windows and DVHA's telehealth billing updates.
Yes, through DVHA's managed care structure under the state's Global Commitment to Health waiver, alongside Medicare through National Government Services and both major commercial carriers.
Timelines vary by payer and specialty. We track each application against the credentialing organization's stated turnaround and follow up before a deadline passes rather than after.
OneCare Vermont and the state's All-Payer ACO Model ended December 31, 2025. Vermont shifted to the federal AHEAD Model for 2026, and we rebuilt claims workflows around that transition rather than OneCare's fee schedule.
Since January 2025, Vermont Medicaid has used two separate place-of-service codes for telehealth: POS 02 for a facility-based site and POS 10 for a patient's home. Commercial payers must reimburse telehealth at parity with in-person visits under S.30, effective September 2025.
No. Gold-card status applies only to specific procedures where a provider has a documented approval history, and it's granted procedure by procedure. We track which of your codes qualify and file for the rest.
Yes. We work with behavioral health, cardiology, oncology, orthopedics, and several other specialties across Vermont, each with coding and prior authorization patterns specific to that specialty.
Talk to us about your claims, your denial rate, or just what changed this year. We'll tell you plainly what needs fixing first.
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